Indications for Elective vs. Urgent Vs. Emergency Diagnostic Lap
Elective: cancer staging, chronic pain
Urgent: SBO, ileus
Emergent: Trauma, iatrogenic injury, perforated viscus
Lysis of adhesions
sharp, blunt, or energy sources can be used
Dx lap of upper abdomen positioning
- Reverse trendelenburg position so abdominal contents shift caudad
- Consider footboard and leg safety strap if steep reverse Tburg
- May need liver retractor
- May needs biopsy and hemostasis tools, US/C-arm, and suturing capability
where do you enter for dx lap of unknown etiology
LUQ and place ports laterally (surgeon and assistant on same size)
Dx lap of liver
mass, bleeding cirrhosis
- Angle scope, tools for biopsy/hemostasis, may need US
- Anterior surface: May need adhesiolysis
- Posterior surface: may need liver retractor, use blunt instruments for retraction
- Avoid bx of vascular lesions
Dx lap of anterior abdominal wall
looks for postop bleeding, adhesions, hernia, tumor
- need angled laparoscope (30deg)
- LUQ access is safest
dx lap for pelvic pathology
- Arms tucked, Trendelenburg position
- Retraction of uterus: uterine manipulator, lap retractior, suture retraction
- Needs instruments for biopsy and hemostasis
Dx lap for appy
tuck L arm or both arms
- trendelenburg position with right side up, lateral position
Dx lap for small bowel
- 2 monitors: one near head and one near feet
- Runs from ligament of Treitz (LUQ) to ileocecal valve (RLQ)
- Place ports along L abdomen
- USE BLUNT GRASPERS and handle mesenteric fat rather than bowel wall
- Use systematic fashion, start at cecum and work proximally
Dx lap SBO
- Initial entry under direct visualization
- Start at ileocecal valve with relatively collapsed bowel, and then identify area of obstruction
- Use care handling dilated bowel
Dx lap for retroperitoneal structures (exposure kidneys, spleen, adrenal glands)
- Best accomplished by lateral position so intestinal contents fall away
- Semi-lateral position allows for both lateral and supine positions
- Want ports at costal margin for best visualization of kidneys and adrenal glands
- May need Tburg and reverse Tburg
- May need to mobilize the colon to access the kidneys and adrenal glands, and para-aortic lymph nodes above the bifurcaton
- RP structures below aortic bifurcation (nodes) are accessed by incision overlying peritoneum
1. Be careful for vessels, ureters, bladder, spermatic cord, and nerves (genitofemoral, obturator, lateral femoral cutaneous nerve)
2. Usually do not require lateral position
3. Usually can do supine position w/ or w/o dorsal lithotomy
Dx lap for trauma
- Should not have severe hemodynamic instability
- Arms tucked, one monitor on each side of patient
- Angled laparoscope for max maneuverability
- May be good for detecting injuries to diaphragm or GI tract
- Reduces non-therapeutic laparotomy rate
